0PowerPoint- focused Echocardiography.pdf

Echo cardiogram in advance

1. Basic EchocardiographyBasic Echocardiography
Wendy Blount, DVMWendy Blount, DVM

2. Echo Technique -AnatomyEcho Technique -Anatomy
Tricuspid valve
•Septal leaflet
•Parietal leaflet
Pulmonic Valve
•Right cusp
•Left cusp
•Intermediate cusp
Mitral valve
•Leaflets are less
distinct
•Posterior & Anterior
Aortic Valve
•Right cusp
•Left cusp
•Septal cusp

3. Echo Technique -AnatomyEcho Technique -Anatomy
RV
•Conus arteriosus -RVOT
•3 papillary muscles
LV
•2 papillary muscles (usually)

4. EchocardiographyEchocardiography
Equipment
•Transducer -
microconvex or cardiac
(sector scanner)
–small footprint
–Fan-shaped beam or sector
•Higher frequency for small animals
•Lower frequency for large animals
•Machines range from 2.5-10 MHz
•5-7 MHz will work fine for most
dogs and cats for echo

5. EchocardiographyEchocardiography
Equipment
•Double window with simultaneous
B and M modes
•Can do measurements on B-mode
or M-mode
•Need a cursor which can measure
mm, or cm marks on the images
•Ability to capture images is
important
•CINe loop is helpful (3-7 sec)

6. EchocardiographyEchocardiography
Preparation
•Thin coated animals –alcohol, part the
hairs, gel
•Thick coated –shave the window –at the
sternum, just behind the right elbow
•Sedation only if needed
–Acepromazine –0.025 mg/lb (max 1 mg)
–Buprenex –0.01-0.02 mg/kg
•Or butorphanol 0.1 mg/lb
–Mix together and give IV
(handout)
–Trazadone (cat study) –lower BP

7. EchocardiographyEchocardiography
Indications
•Murmur, CHF
•Gallop Rhythm
•Arrhythmia
–Tachycardia
–Bradycardia
–Pulse deficits
•Muffled heart or lung
Sounds
•Syncope
•Cyanosis
•Effusions
–pleural,
pericardial, abdominal•Cardiomegaly
•Pulmonary edema
•Heartworm Disease
•Thoracic Mass
•Splenic Mass
•Thromboembolism

8. EchocardiographyEchocardiography
Positioning for 8 standard views
•Right lateral recumbency (>90%)
•Cardiac table is nice but not always
necessary
•Sonographer needs a stool or chair
•Placement of probe:
–Feel the apical beat, and put your probe there
(probe marker cranial)
–Imagine the longitudinal axis of the heart,
probe at 90
o
(short axis views)
–Adjust 1 intercostal space Cr or Cd PRN
–Rarely move the probe head –just fan and
rotate

9. EchocardiographyEchocardiography
Positioning for 8 standard views
•Right lateral recumbency (90%)
•Cardiac table is nice but not necessary
•Sonographer needs a stool or chair
•Placement of probe:
–Feel the apical beat, and put your probe
there (probe marker cranial)
–Imagine the longitudinal axis of the heart,
probe at 90
o
(short axis views)
–Adjust 1 intercostal space Cr or Cd PRN
–Rarely move the probe head –just fan and
rotate

10. EchocardiographyEchocardiography
Equipment
microconvex probe
rib shadow artifact
microconvex probe
lung shadow artifact
abdominal settings
cardiac probe

11. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
•Fan from base to apex, until you are just below
the chordae, and the LV papillary muscles
appear (“Mushroom” view)
•Rotate until PM are the same size
•If you are getting a rib or lung shadow, try one
intercostal space cranial or caudal
•Rock cranial or caudal to center the heart on
the screen

12. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Abbreviations –Structures
•P –pericardium
•RV–right ventricle
•IVS–intraventricular septum
•LV–left ventricle
•PPM–posterior papillary muscle
•APM–anterior papillary muscle*

13. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Abbreviations –Structures –
•P –pericardium
•RV–right ventricle
•IVS–intraventricular septum
•LV–left ventricle
•PPM–posterior papillary muscle
•APM–anterior papillary muscle
dog

14. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Abbreviations –Structures –
•P –pericardium
•RV–right ventricle
•IVS–intraventricular septum
•LV–left ventricle
•PPM–posterior papillary muscle
•APM–anterior papillary muscle
cat

15. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle

16. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Normal/Abnormal Features
Assess volume status
•normal–round with adequate fill in diastole
•Volume contracted –oval or small round, walls
look artifactually thickened & contraction intense
Check for pericardial effusion

17. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
•Cord slightly toward the head

18. 1. Short Axis –Left Ventricle
Technique
1. Short Axis –Left Ventricle
Technique

19. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Measurements (RV, RVID)
•IVSTd-IntraVentricular Septum Diastole
•LVIDd-LV Inner Diameter Diastole
•LVPWd–LV Posterior Wall Diastole
•IVSTs-IntraVentricular Septum Systole
•LVIDs-LV Inner Diameter Systole
•LVPWs–LV Posterior Wall Systole

20. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Measurements (RV, RVID)
•IVSTd=IVSd=VSd
•LVIDd=LVd =LVLd
•LVPWd=LVFWd=LVWd
•IVSTs=IVSs=VSs
•LVIDs=LVs =LVLs
•LVPWs=LVFWs=LVWs

21. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Measurements -Calculated
•FS –fractional shortening
(LVIDd –LVIDs)
LVIDd
–Assumes perpendicular to myocardium
–Assumes contractility is uniform in the LV
–Extremes in preload and afterload can affect FS, as
well as myocardial function

22. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Measurements -Calculated
•FS –fractional shortening
•AKA shortening fraction (SF)
–>30% in the dog
–>40% in the cat
–>45% if MR is compensated

23. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Measurements -Tips
•Make sure you don’t include PM in the LVPW
measurement

24. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Measurements -Tips
•Don’t include PM in the LVPW measurement
–If you do, your LVPW will be artifactually thicker
–Clue–check for this if LVPW is much thicker than IVS
•Make sure you are not too far apical
–If you are, your LVID will be artifactually small
–And LVPW will be artifactually thick
–Measure at top of PM as they transition to chordae

25. 1. Short Axis –Left Ventricle1. Short Axis –Left Ventricle
Measurements -Tips
•Measure 3-5 times
–Take the average
–Throw out any outliers
•Several sets of normals published
–1-2mm outside normal may not always be
significant

26. 2. Short Axis –Apex2. Short Axis –Apex
Structures
•Pericardium
•May or may not see RV
•LV apical lumen –no papillary muscles
No measurements here

27. 2. Short Axis –Apex2. Short Axis –Apex
Structures
•Pericardium
•May or may not see RV
•LV apical lumen –no papillary muscles
No measurements here

28. 3. Short Axis –Chordae Tendinae3. Short Axis –Chordae Tendinae
Structures –”Windshield Wiper” View
•Pericardium
•RV
•LV
•CH-
Chordae Tendinae (posterior & anterior)*
No measurements here

29. 3. Short Axis –Chordae Tendinae3. Short Axis –Chordae Tendinae
Structures
•Pericardium
•RV
•LV
•CH-
Chordae Tendinae (posterior & anterior)
No measurements here
large dog

30. 3. Short Axis –Chordae Tendinae3. Short Axis –Chordae Tendinae
Structures
•Pericardium
•RV
•LV
•CH-
Chordae Tendinae (posterior & anterior)
No measurements here
small dog

31. 3. Short Axis –Chordae Tendinae3. Short Axis –Chordae Tendinae
Structures -
•Pericardium
•RV
•LV
•CH-
Chordae Tendinae (posterior & anterior)
No measurements here

32. 3. Short Axis –Chordae Tendinae3. Short Axis –Chordae Tendinae
Structures -
•Pericardium
•RV
•LV
•CH-
Chordae Tendinae (posterior & anterior)
No measurements here
cat

33. 4. Short Axis –Mitral Valve4. Short Axis –Mitral Valve
Structures –“Fish Mouth” View
•Pericardium
•RV
•RV Papillary Muscles
•LVOT
•MV-Mitral Valve (Posterior & Anterior)*

34. 4. Short Axis –Mitral Valve4. Short Axis –Mitral Valve
Structures –“Fish Mouth” View
•Pericardium
•RV
•RV Papillary Muscles
•LVOT
•MV-Mitral Valve (Posterior & Anterior)
Large Dog

35. 4. Short Axis –Mitral Valve4. Short Axis –Mitral Valve
Structures –“Fish Mouth” View
•Pericardium
•RV
•RV Papillary Muscles
•LVOT
•MV-Mitral Valve (Posterior & Anterior)
Small Dog
Need to zoom in

36. 4. Short Axis –Mitral Valve4. Short Axis –Mitral Valve
Structures –“Fish Mouth” View
•Pericardium
•RV
•RV Papillary Muscles
•LVOT
•MV-Mitral Valve (Posterior & Anterior)
Med Dog with MVD
Need to Zoom Out a little

37. 4. Short Axis –Mitral Valve4. Short Axis –Mitral Valve
Structures –“Fish Mouth” View
•Pericardium
•RV
•RV Papillary Muscles
•LVOT
•MV-Mitral Valve (Posterior & Anterior)
Cat

38. 4. Short Axis –Mitral Valve4. Short Axis –Mitral Valve
•Cord close to perpendicular to the skin

39. 4. Short Axis –Mitral Valve4. Short Axis –Mitral Valve
Measurement
•EPSS –E-Point to Septal Separation
–If increased above normal, can denote
enlarged LV, volume overload and often
poor systolic function
–Less than 6 mm in large dogs
–Less than 3-5 mm in small dogs and cats

40. 4. Short Axis –Mitral Valve4. Short Axis –Mitral Valve
Measurement
•EPSS –E-Point to Septal Separation
–If increased above normal, can denote
enlarged LV, volume overload and often
poor systolic function
–Less than 6 mm in large dogs
–Less than 3-5 mm in small dogs and cats

41. 4. Short Axis –Mitral Valve4. Short Axis –Mitral Valve
Measurement
•EPSS –E-Point to Septal Separation
–If increased above normal, can denote
enlarged LV, volume overload and often
poor systolic function
–Less than 6 mm in large dogs
–Less than 3-5 mm in small dogs and cats

42. 4. Short Axis –Mitral Valve4. Short Axis –Mitral Valve
Normal
MVD
AMV
PMV
LV
RV

43. 5. Short Axis –Aortic Valve5. Short Axis –Aortic Valve
Structures –“Mercedes Sign” View
•RVOT –Right Ventricular Outflow Tract
•TV–Tricuspid Valve
•PV–Pulmonic Valve
•Ao–Aortic Valve
•LA–Left Atrium*

44. 5. Short Axis –Aortic Valve5. Short Axis –Aortic Valve
Structures –“Mercedes Sign” View
•RVOT –Right Ventricular Outflow Tract
•TV–Tricuspid Valve
•PV–Pulmonic Valve
•Ao–Aortic Valve
•LA–Left Atrium
Normal Dog
Ao
LA

45. 5. Short Axis –Aortic Valve5. Short Axis –Aortic Valve
Structures –“Mercedes Sign” View
•RVOT –Right Ventricular Outflow Tract
•TV–Tricuspid Valve
•PV–Pulmonic Valve
•Ao–Aortic Valve
•LA–Left Atrium
Dog LA
Enlargement
Ao
LA

46. 5. Short Axis –Aortic Valve5. Short Axis –Aortic Valve
Structures –“Mercedes Sign” View
•RVOT –Right Ventricular Outflow Tract
•TV–Tricuspid Valve
•PV–Pulmonic Valve
•Ao–Aortic Valve
•LA–Left Atrium
Cat
obliqued

47. 5. Short Axis –Aortic Valve5. Short Axis –Aortic Valve
•

48. 5. Short Axis –Aortic Valve5. Short Axis –Aortic Valve
•Cord toward the sternum
•Point beam to the left shoulder
•Some call it the “5 Chamber Short View”

49. 5. Short Axis –Aortic Valve5. Short Axis –Aortic Valve
•

50. 5. Short Axis –Aortic Valve5. Short Axis –Aortic Valve
Measurements
•Aos–at largest dimension (systole)
•LAd–at largest dimension (diastole)
•LA:Ao–
–0.8 to 1.3 in dogs
–0.8 to 1.4 in cats

51. 5. Short Axis –Aortic Valve5. Short Axis –Aortic Valve
Normal
Enlarged LA
Ao
LA

52. 5. Short Axis –Aortic Valve5. Short Axis –Aortic Valve
Normal
Enlarged LA
Ao
LA

53. 6. Short Axis –Pulmonary Artery6. Short Axis –Pulmonary Artery
Structures
•RA –Right Atrium
•Ao –Aorta (ascending)
•MPA –MainPulmonary Artery
–LPA –left pulmonary artery
–RPA –right pulmonary artery
•CaVC –Caudal Vena Cava*

54. 6. Short Axis –Pulmonary Artery6. Short Axis –Pulmonary Artery
•Lift the cord
•Point the beam toward the head
•This can be a difficult view in the barrel
chested dog
•If present, may see PDA here, entering
the far field into the MPA from the
descending aorta
PDA

55. 6. Short Axis –Pulmonary Artery6. Short Axis –Pulmonary Artery
•Lift the cord
•Point the beam toward the head
•This can be a difficult view in the barrel
chested dog
•If present, may see PDA here, entering
the far field into the MPA from the
descending aorta
PDA
Dog

56. 6. Short Axis –Pulmonary Artery6. Short Axis –Pulmonary Artery
•Lift the cord
•Point the beam toward the head
•This can be a difficult view in the barrel
chested dog
•If present, may see PDA here, entering
the far field into the MPA from the
descending aorta
PDA
Cat

57. 5. Short Axis –Pulmonary Artery5. Short Axis –Pulmonary Artery
•

58. 5. Short Axis –Pulmonary Artery5. Short Axis –Pulmonary Artery
•

59. 7. Long Axis –4 Chamber7. Long Axis –4 Chamber
Technique
•Get short axis “mushroom” view
•Rotate 90 degrees counterclockwise
•“Thumb to the Bum”
•Pick up the cord and point the beam to
the TL junction of the spine

60. 7. Long Axis –4 Chamber7. Long Axis –4 Chamber
Structures
•RV –Right Ventricle
•RA –Right Atrium –difficult to view completely
•TV–Tricuspid Valve
•LV –Left Ventricle
•LA –Left Atrium
•MV –Mitral Valve, PM–papillary muscle*

61. 7. Long Axis –4 Chamber7. Long Axis –4 Chamber
Structures
•RV –Right Ventricle
•RA –Right Atrium –difficult to view completely
•TV–Tricuspid Valve
•LV –Left Ventricle
•LA –Left Atrium
•MV –Mitral Valve, PM–papillary muscle
LV
RV
Normal LV:RV > 3:1

62. 7. Long Axis –4 Chamber7. Long Axis –4 Chamber
Structures
•RV –Right Ventricle
•RA –Right Atrium –difficult to view completely
•TV–Tricuspid Valve
•LV –Left Ventricle
•LA –Left Atrium
•MV –Mitral Valve, PM–papillary muscle
RV
LV

63. 7. Long Axis –4 Chamber7. Long Axis –4 Chamber
Structures
•RV –Right Ventricle
•RA –Right Atrium –difficult to view completely
•TV–Tricuspid Valve
•LV –Left Ventricle
•LA –Left Atrium
•MV –Mitral Valve, PM–papillary muscle
RA
LA
Normal LA:RA = 1:1

64. 7. Long Axis –4 Chamber7. Long Axis –4 Chamber
Structures
•RV –Right Ventricle
•RA –Right Atrium –difficult to view completely
•TV–Tricuspid Valve
•LV –Left Ventricle
•LA –Left Atrium
•MV –Mitral Valve, PM–papillary muscle
Normal LV:IVS = 4-6:1
IVS
LV
1
2
3
4
5

65. 7. Long Axis –4 Chamber7. Long Axis –4 Chamber

66. 7. Long Axis –4 Chamber7. Long Axis –4 Chamber
Normal Features
•LVID:RVID >2-3:1
•RVFW< LVFW 1:2-3
•RA:LA = approximately 1:1
•LVID:IVS= 4-6:1
•FS>30% in the dog, >40% in the cat

67. 7. Long Axis –4 Chamber7. Long Axis –4 Chamber
•Beam axis with long axis of the heart
•45
o
to long axis of the dog
•If right handed –thumb on the notch

68. 7. Long Axis –4 Chamber
Technique
7. Long Axis –4 Chamber
Technique

69. 8. Long Axis –LVOT8. Long Axis –LVOT
Structures –“In Flow Out Flow View”
•RV, TV, RA
•LV, PM, MV
•Very edge of the LA
•LVOT –AoV (LC, SC), ascendingAo
•RPA –Right Pulmonary Artery*

70. 8. Long Axis –LVOT8. Long Axis –LVOT
Structures
•RV, TV, RA
•LV, PM, MV
•Very edge of the LA
•LVOT –AoV (LC, SC), ascendingAo
•RPA –Right Pulmonary Artery

71. 8. Long Axis –LVOT8. Long Axis –LVOT
Structures
•RV, TV, RA
•LV, PM, MV
•Very edge of the LA
•LVOT –AoV (LC, SC), ascendingAo
•RPA –Right Pulmonary Artery

72. 7. Long Axis –LVOT7. Long Axis –LVOT

73. 8. Long Axis –LVOT8. Long Axis –LVOT
•Lift the cord
•Point the beam to the left shoulder
•Rotate probe 10-15
o
counterclockwise
(“Thumb to Bum”)
•Some call it the “5 Chamber Long View”

74. 7. Long Axis –LVOT Technique7. Long Axis –LVOT Technique

75. 7. Long Axis –LVOT Optimization7. Long Axis –LVOT Optimization

76. Dog RV Measurement ValuesDog RV Measurement Values
•RVWd –less than LVWd
•RVIDd –1/3 or less of LVIDd

77. EchocardiographyEchocardiography
Emergency Cardiac Evaluation –GlobalFAST
®
1.VetBLUE
®
(Veterinary Bedside Lung Ultrasound Exam)
-
sternal recumbency or standing
–Dry lungs in all 8 spots –No LHF
–Wet lungs (esp Ph) –possible LHF, possible severe PHT
–Dry lung, wet lung, nodules, wedges –heartworm disease
2. TFAST
®
echo views
-sternal or right lateral recumbency
–LV short axis (mushroom, batman) –estimate volume and
contractility
–Long axis 4 chamber –PHT or PS
•RV:LV –normal <1:3, PHT >1:1 –1:2
–LA:Ao –LA enlargement, possible LHF

78. EchocardiographyEchocardiography
Emergency Cardiac Evaluation –GlobalFAST
®
3.AFAST
®
-R lat recumbency
•DH View
–normal caval bounce -rules out RHF and confirms
normovolemia
–Flat cava -hypovolemia, possible forward LHF
–Fat cava -possible RHF, pericardial effusion (PCE)
–Pericardial effusion, GB edema, fat cava –RHF, pericardial
tamponade
•SR, CC and HR views
–look for & score fluid (AFS)
–collect fluid at HR
–look for spleen mass if hemorrhagic ascites or PCE

79. Interrogating the RA
Left Parasternal Long Axis
Interrogating the RA
Left Parasternal Long Axis
•Change from right to left lateral recumbency
•Feel for the apical beat, and place probe there
•This is often more caudal and farther from the
sternum compared to the other side
•Align beam axis with the long axis of the heart,
45
o
to the long axis

80. Interrogating the RA
Left Parasternal Long Axis
Interrogating the RA
Left Parasternal Long Axis
•Change from right to left lateral recumbency
•Feel for the apical beat, and place probe there
•This is often more caudal and farther from the
sternum compared to the other side
•Align beam axis with the long axis of the heart,
45
o
to the long axis

81. Cat Echo Normal ValuesCat Echo Normal Values
•IVSTd –3-6 mm
•LVIDd –10-21 mm
•LVPWd–3-6 mm
•IVSTs -4-9
•LVIDs–4-11 mm
•LVPWs–4-10 mm
•Aos–6-12 mm
•LAd–7-15 mm
•FS->40%
•EPSS-0-3 mm
•EF ->70%
•LA:Ao –0.8-1.4
•RVIDd -3-7 mm
•RVWd-<3 mm
(form)

82. Ferret Echo Normal Values (Mean)Ferret Echo Normal Values (Mean)
•LVIDD –11.0 mm
•LVIDS-6.4 mm
•LVPW-3.3 mm
•FS-42%
•EPSS-0

83. Cat Echoes for DummiesCat Echoes for Dummies

84. SummarySummary
PowerPoint-
.pptx, .pdf 1 & 6 slides per page
In Clinic Forms:
•Echocardiogram (back) -.docx, .pdf
•Oncura Echo Protocol
•Cardiac Evaluation Form (exam front, echo
back)
Scientific Articles:
•Trazadone for Echocardiogram in the Cat

85. SummarySummary
Vet Handouts
•Chart–cardiac safe sedation and normal echo values for
dogs (1-120 pounds)
•Oncura Echocardiography ManualHidden Slides
•Anatomy of the heart valves
•Indications for Echocardiogram
•Emergency Cardiac US Exams –TFAST® & VetBLUE®

86. AcknowledgementsAcknowledgements
Kittleson, Mark, DACVIM -Cardiology
•Small Animal Cardiovascular Medicine,
Veterinary Information Network. Chapter
6–Echocardiography
Boon, June –Colorado State U
•Academy of Veterinary Imaging Echo Intro
Huber B, Huber J, Merrell S, Poteet B
•Oncura Partner’s Echocardiography Manual